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Even with the Best Preparation, Errors Will Happen

When this column addresses adverse events, we frequently try to identify some action or inaction that, if addressed differently, might have led to a better outcome. Though thankfully rare, errors nevertheless can occur even with a spotless work-up.

A 53-year-old patient first visited Dr. GS, a general surgeon, complaining of a lump in her right breast. An ultrasound from two months earlier showed a lesion at 10 o’clock, and upon examination, Dr. GS noted a small but definite non-mobile mass. Dr. GS recommended an excision and several months later, he performed a right breast lumpectomy.

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Pathology results for the excision showed a 1.4 cm invasive, moderately differentiated, ductal carcinoma, stage 1A. Dr. GS discussed the results with his patient and documented an early plan for a probable mastectomy and axillary node biopsy, pending the final pathology report and an oncology consult.

When the final pathology report was available later that month, Dr. GS discussed with his patient (with her two daughters interpreting) his assessment of invasive right breast cancer and the options for mastectomy versus conservation. Dr. GS charted the patient would “like to hear more about reconstruction as is leaning towards mastectomy.” In order to assess her options, the patient was to undergo a bilateral breast MRI and have oncology, radiation oncology, and plastic surgery consultations.

While pursuing those consultations, the patient and Dr. GS discussed lumpectomy versus mastectomy over the next several visits, with the patient “still leaning towards conservation.” Dr. GS explained that even with a partial mastectomy, the nipple needed to be removed. Dr. GS documented that his patient had been told by her plastic surgeon that reconstruction after a partial mastectomy with nipple and areolar excision was not possible. The patient nevertheless stated her preference for a lumpectomy and conservation. She signed a consent for a wide local excision, including the areola and nipple.

On surgery day, the patient was admitted for a “right partial mastectomy,” which was noted as the chief complaint on the hospital admission sheet. However, Dr. GS performed (and described in his final report) a right breast mastectomy and lymph node biopsies. Though the pathology report described the procedure to be done as a “right partial mastectomy and removal of areolar/nipple complex” the report described the specimen submitted as “right breast mastectomy.” The lymph nodes were negative for malignancy.

In a follow-up office visit two days later accompanied by a daughter, the patient complained of pain and asked Dr. GS why he performed a mastectomy. Later that day, Dr. GS reviewed the records and noted the patient’s consent for a partial mastectomy. He called the patient and, through her daughter, acknowledged the error and offered his sincere apologies. Further follow-up office visits by the patient were uneventful. A lawsuit by the patient closed without going to trial.

Remarkable in the review of the medical records (including the customary “time out” in the operating room) was the absence of any factor to explain Dr. GS’s performance of a different procedure than planned. (Though one of his early notations, that the patient would “like to hear more about reconstruction as is leaning towards mastectomy” is a bit incongruous, Dr. GS’s subsequent charting is clear that the patient was leaning toward, and ultimately consented to, a partial procedure.)

This column typically strives to find a teachable moment in a bad outcome, usually by identifying some risk management shortfall in a fact pattern. Sometimes, of course, we humans can make mistakes even while taking all customary precautions. There’s a lesson in that as well.   

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to

Interested in reading more case studies? Request a free copy of Medicine on Trial, a compilation of more than 80 litigated cases accompanied by commentary from Gordon Ownby.